Adapting Problem Management Plus for Implementation: Lessons Learned from Public Sector Settings Across Rwanda, Peru, Mexico and Malawi.

Problem Management Plus (PM+) is a low-intensity psychological intervention developed by the World Health Organization that can be delivered by nonspecialists to address common mental health conditions in people affected by adversity. Emerging evidence demonstrates the efficacy of PM+ across a range of settings. However, the published literature rarely documents the adaptation processes for psychological interventions to context or culture, including curriculum or implementation adaptations. Practical guidance for adapting PM+ to context while maintaining fidelity to core psychological elements is essential for mental health implementers to enable replication and scale. This paper describes the process of contextually adapting PM+ for implementation in Rwanda, Peru, Mexico and Malawi undertaken by the international nongovernmental organization Partners In Health. To our knowledge, this initiative is among the first to adapt PM+ for routine delivery across multiple public sector primary care and community settings in partnership with Ministries of Health. Lessons learned contribute to a broader understanding of effective processes for adapting low-intensity psychological interventions to real-world contexts.

Stepped care for depression at integrated chronic care centers (IC3) in Malawi: study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: Malawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease-including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes. METHODS: We will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model's cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model. DISCUSSION: This study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence. TRIAL REGISTRATION: ClinicalTrials.gov NCT04777006 . Registered on 1 March, 2021.

The systematic development of a mobile phone-delivered brief intervention for hazardous drinking in India.

BACKGROUND: The treatment gap for alcohol use disorders (AUD) in India is the highest among all mental health and substance use disorders. Despite evidence of the cost effectiveness of brief interventions (BIs) for hazardous drinking, implementation in low- and middle-income countries (LMICs) is rare due to several human resource-related barriers. This paper describes the processes and outputs of a study aimed at systematically developing a mobile phone-delivered BI to overcome such barriers. METHODS: This is a mixed methods study with four steps: (1) Review of existing relevant evidence base by extracting data from studies cited in two recent, relevant and high-quality systematic reviews; (2) In-depth interviews (IDIs) with 11 national experts in addictions research and practice, and 22 hazardous drinkers; (3) Delphi survey (2 rounds) to identify components for the intervention package through consensus building; and (4) Content and intervention development workshops with a range of stakeholders to develop the intervention package. RESULTS: The research team sourced 72 journal articles from two selected systematic reviews. Key content areas extracted from the studies included facts and statistics about health related to drinking behavior, self-reflection, goal-setting messages, motivational messages, and skills to manage risky situations. The IDIs with experts and hazardous drinkers endorsed most of these content areas as well. The Delphi survey achieved consensus on 19 content areas, which included targeted recommendations, personalized feedback and information, goal management, and coping skills. The content and intervention development workshops resulted in an intervention package delivered over 8 weeks, with the following seven themes guiding the content of the weekly messages: safe drinking/health education, alcohol reduction, drinking and risk management, drinking alternatives, situational content, urge management, and maintenance and relapse prevention. CONCLUSION: The research team designed this study to consider contextual factors while developing the intervention, which is important to ensure acceptability and feasibility of the intervention. Interestingly, the contextually informed intervention components had several commonalities with BIs developed and tested in high-income countries.